<form action="" method="post" autocomplete="on">
    <p><input name="date" !required="required" type="text" placeholder="гггг-мм-дд" /></p>
    <p>{msg}</p>
    <br />
    <p><input type="checkbox" name="check_yes" value="yes" /> подтверждаю <input class="button" type="submit" value="Да" /> &nbsp; &nbsp; <input class="button" type="button" onclick="return location.href = '/?action=panel'" value="Отменить"/></p>
</form>

